Shoulder Pain Management

Tendonitis, Bursitis and Impingement Syndrome

Subacromial impingement, also known as rotator cuff tendonitis or bursitis, occurs when the rotator cuff becomes irritated underneath the acromion. The reason why this happens is unclear. Some people are thought to be born with a “hooked” acromion that will predispose them to impingement. Other patients develop impingement due to intrinsic rotator cuff weakness. Because the rotator cuff is a humeral head centralizer, weakness of the cuff will allow it to ride up and impinge on the acromion. The result is inflammation of the bursa between the rotator cuff and the acromion.

Key Observations
• Pathology involves inflammation of the bursa between the rotator cuff and the acromion
• The most common symptom is pain
• The condition is more common in adults who are >40 years of age

The typical patient has history of overactivity and onset of moderate to occasionally severe pain with activity. A complete history of the patient is critical to the diagnosis, and will help identify predisposing factors, such as participation in sports or work-related activities that involve overhead motion.

Clinical Clues
• Pain starts after recent overactivity
• Motion is painful
• Active abduction is painful

Physical Findings

The cervical spine should be examined for abnormalities, including radiculopathy and degenerative joint disease that may cause referred pain in the shoulder. Inspect and palpate the shoulder and determine muscle strength and range of motion.

The impingement sign test (Fig. 1), is performed by standing behind the patient and passively elevating the arm in the scapular plane while stabilizing the scapula.¹ Pain usually is elicited in the arc between 50-130 degrees of forward elevation (Fig. 2). The acromiohumeral distance will be decreased substantially. This distance is decreased further by internally rotating the humerus, spur formation, or the presence of an acromial spur (Fig. 3). Hawkins and Kennedy modified the maneuver by passively internally rotating the arm after passively elevating the arm to 90 degrees (Fig. 4).²

Figure 1: Impingement sign is elicited by standing behind the patient and passively elevating the arm in the scapular plane while stabilizing the scapula.

Figure 2: With impingement, the painful arc of motion is generally between 50-130 degrees of forward elevation, the mid arc range of motion.

Figure 3: Three types of acromion: Type I, flat; Type II, curved and Type III, hooked.³

Figure 4: Hawkins sign – modification of the Neer sign. This test is performed by placing the arm in 90 degrees of forward flexion, with the elbow flexed 90 degrees. The examiner then passively internally rotates the arm maximally. A positive test is signified by production of pain.

Clinical Course

Most patients with impingement syndrome or small rotator cuff tearing will recover to normal function within 6 months. Physical therapy and NSAIDs and/or analgesia will aid recovery. The minority of patients who have persistent or increasing symptoms should be evaluated for possible surgical interventions. Regardless of the etiology of shoulder impingement, most patients will improve with conservative measures over 6 months, and some continue to improve up to 18 months from initiation of treatment.

Know When to Refer
• Patient not responding to conservative treatment after 3 to 6 months
• Traumatic glenohumeral instability
• Full-thickness rotator cuff tears
• Symptomatic os acromiale
• Ganglion cyst of the shoulder
• Recalcitrant adhesive capsulitis

The ICD9 codes for tendonitis, bursitis and subacromial impingement are 726.2 (Other affections of shoulder region, not elsewhere classified), 726.10 (Disorders of bursae and tendons in shoulder region, unspecified) and 726.0 (Adhesive capsulitis of shoulder).

The information contained on this site is provided for your informational purposes only and represents no statement, promise, or guarantee by DePuy Orthopaedics, Inc. concerning levels of reimbursement, payment or charge. Similarly, all billing codes and revenue codes mentioned above are supplied for information purposes only and represent no statement, promise or guarantee by DePuy, Inc. that these codes will be appropriate or that reimbursement will be made.

References